Case Study: A Pickleball Player's Stubborn Tennis Elbow — and Where Shockwave Fit In

Everything below is a composite — an illustrative case built from the presentations we see most often in weekend athletes across St. Charles County. It is not a specific patient and contains no protected health information. The point is to show how we actually think through a case. Outcomes here describe a typical trajectory; results vary from person to person.

The presentation

Picture a pickleball player in his mid-fifties — three or four mornings a week on the courts, plus the occasional weekend tournament. He first noticed a nagging ache on the outer bump of his elbow a few months back. At first it was just a warm-up stiffness that faded once he got going. Then it started lingering after play, then showing up when he shook hands, lifted a coffee mug, or twisted a jar lid.

By the time he came in, the pattern was clear to him: gripping the paddle lit it up, especially on those hard two-handed backhands, and the pain hung around for a day or two afterward. He’d done the sensible things — a week off, ice, a compression strap from the pharmacy — and each time he felt better, went back to playing, and was right back where he started. That stop-start cycle is the classic story of lateral epicondylitis, better known as tennis elbow, and it’s exactly why rest alone so often disappoints.

Here’s the thing worth saying plainly: he didn’t injure it in one dramatic moment. This is an overuse tendon problem that built quietly over weeks of repeated gripping and loading — the paddle just happened to be an efficient way to keep poking the same sore tendon.

What the exam found

Before we treat anything, we confirm what we’re treating. Outer-elbow pain has a few possible sources, and they don’t all respond to the same plan, so the assessment started by ruling things in and out.

• Where exactly it hurt. Pressing on the lateral epicondyle — the outer bony bump where the wrist-and-finger extensor tendons anchor — reproduced his familiar pain. That’s the hallmark of tennis elbow, and it’s a different address than golfer’s elbow, which sits on the inner bump.
• What provoked it. Gripping and straightening the wrist against gentle resistance, and lifting with the palm facing down, both flared the outer elbow. Those loaded-tendon tests are far more telling than pain at rest.
• What it wasn’t. We checked the neck and screened for nerve involvement, because pain can refer down the arm from the cervical spine. No numbness, tingling, or weakness in the hand, no neck-driven pattern, no history of a fall or blow to the elbow — all reassuring, and all reasons this looked like a local tendon issue rather than something needing a different workup.

We also looked upstream. His grip strength was down on that side (normal when a tendon is guarding), his forearm and shoulder-blade muscles were doing the job a bit inefficiently, and his paddle grip was on the tight, tense end. None of that caused the tendon pain by itself, but each piece was quietly feeding it.

The plan

Chronic tendon pain has a well-earned reputation for being stubborn, and the honest reason is that it’s usually not a simple inflammation you can rest away — it’s a disorganized, under-loaded tendon that never finished repairing. So the plan centered on the one thing that actually rebuilds tendon: the right amount of load, applied progressively.

• Loading-based tendon rehab. The backbone was slow, controlled forearm work — including eccentric (lengthening) wrist exercises — dosed to a level that challenged the tendon without flaring it. This is the part that does the real remodeling, and it lives in his Corrective Exercise Program so the load progresses on purpose rather than by accident.
• Hands-on care. Soft-tissue work on the tight forearm extensors and some attention to the wrist, elbow, and shoulder-blade mechanics helped him move and grip with less guarding, which made the loading exercises more comfortable to actually do.
• Grip and activity modification. We dialed his paddle grip and playing volume back into a range the tendon could tolerate — not total rest, but a smarter dose. As anyone who takes their game seriously knows, staying on the court usually means managing load, not avoiding it.

And because his case had been stuck for months — stalled, not acute — we added shockwave therapy. Shockwave uses focused acoustic pulses to essentially wake up a chronic tendon’s repair response, stimulating blood flow and cellular activity in tissue that had quit healing. It shines precisely in these long-standing cases where rest and a brace have already been tried and failed. We ran a short course of weekly sessions alongside — never instead of — his loading work. Shockwave for chronic, stalled tendons is one of the tools we reach for at our Cottleville clinic.

How recovery typically goes

This is where we set honest expectations, because tendon timelines are slower than most people hope. Tendon tissue remodels over weeks to months, not days, and a case that’s been simmering for half a year doesn’t reverse in a week or two.

A typical trajectory looks like this: the sharpest daily-activity pain — the jar lids and handshakes — often eases in the first few weeks as guarding settles and the tissue starts responding. Return to comfortable play tends to come later, and it comes in steps: more court time, harder shots, longer sessions, each added only when the tendon tolerates the last. Some people move faster, some slower. A minority need a longer runway, and if a tendon simply won’t progress, that’s our cue to loop in a physician for imaging or other options rather than keep pushing.

Tendons don’t heal on your schedule — they heal on the schedule of the load you give them.

None of this is a guarantee, and it isn’t a cure you buy in a single visit. It’s a rebuilding process, and the people who do best are the ones who trust the slow part.

When to see a physician first

Most outer-elbow pain is a mechanical tendon issue that responds to movement and load. But some signs point elsewhere and deserve a medical workup before anything else: pain that followed a real fall or direct blow to the elbow, numbness, tingling, or weakness in the hand, a joint that’s hot or swollen, fever, or pain that wakes you at night or keeps worsening despite sensible care. Chiropractic and rehab work alongside your physician here — they complement medical care, they don’t replace the evaluation those red flags call for.

Keeping it from coming back

The most reliable way to keep tennis elbow from returning is to leave the tendon stronger and better-managed than it was before it flared. For our composite player, that meant a few durable habits:

• Keep the forearm strong. A short, ongoing dose of grip and wrist strengthening two or three times a week keeps the tendon resilient long after the pain is gone. This is the part people quit too early — and quitting is how it comes back.
• Manage load, don’t just chase it. Ramp playing time and intensity gradually, especially after a layoff or before a tournament. A relaxed grip and a paddle set-up that isn’t fighting his hand take a surprising amount of strain off the tendon.
• Warm up the grip. A few minutes of easy wrist and forearm movement before play primes the tissue for what’s coming.
• Treat early flares early. A twinge that lingers more than a couple of weeks is worth a look before it becomes another months-long saga.

That combination — a rebuilt tendon, smarter load, and a maintenance habit that sticks — is what turns a recurring nuisance into a closed chapter.